1104909639 NPI number — WELLDYNE, INC.

Table of content: (NPI 1104909639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104909639 NPI number — WELLDYNE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLDYNE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104909639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7472 S TUCSON WAY
Provider Second Line Business Mailing Address:
SUITE 100-B
Provider Business Mailing Address City Name:
CENTENNIAL
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80112-4452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-641-8475
Provider Business Mailing Address Fax Number:
800-530-8589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7472 S TUCSON WAY
Provider Second Line Business Practice Location Address:
SUITE 100-B
Provider Business Practice Location Address City Name:
CENTENNIAL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80112-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-641-8475
Provider Business Practice Location Address Fax Number:
800-530-8589
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAIN
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
303-645-2613

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  370000059 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X , with the licence number: 370000059 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0613302 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7C0059 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03001245 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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